Provider Demographics
NPI:1457683021
Name:BUSH, JESSICA DAWN (MA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DAWN
Last Name:BUSH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 LEXINGTON GREEN LN
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1015
Mailing Address - Country:US
Mailing Address - Phone:407-792-0900
Mailing Address - Fax:407-369-8959
Practice Address - Street 1:1414 LEXINGTON GREEN LN
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1015
Practice Address - Country:US
Practice Address - Phone:407-792-0900
Practice Address - Fax:407-369-8959
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT13733106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist